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AP# <br /> APz'50 2L4 <br /> San Joaquin County Environmental Health Department <br /> _ Operating Permit Fora <br /> i'acllltyName 777�wrw fly _ J'1.+e f/f�r��S <br /> Site Address ( i ` ' -� City State ZIP <br /> Business Phone' 55N or Tax 04 <br /> Facillly Mailing Address pity State ZIP <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Facility Owner <br /> First Name ast n me <br /> Home Address City State ZIP�� <br /> Mailing Address City State Zip <br /> K — <br /> Phone Phone Email <br /> Billing Party <br /> First Name Last name <br /> Wilin Address City State ZIP <br /> Phone —4 6 2-3Phone <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business,and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES andlor HDURL Y CHARGES associated with this operation will <br /> be blFed tome at the address ldontlfled above as the 81LVNG AooREss far this site. l also certify that all Information provided on this application <br /> Is true and correct;and that all regulated act[vitles will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes <br /> andlor Standards and STATE andlor FEDERAL Laws and Re ulations. <br /> Applicant Name Signature <br /> Title date Driver's License R <br /> [Photocopy Required} <br /> EHO Use Only <br /> Assigned TO //I/S' Unked FA 1D ,�,��c, � Record Number <br /> gate g!+ PE I�{I ITS <br /> Permit Valid from to Invoice A <br /> Amount Pald Payme Received By <br /> C7 cash <br /> N1,eckmatlon it �(I V <br />